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Risk of Cerebral Embolization with Caseous Calcification of the Mitral Annulus: Review Article

View Article: PubMed Central - PubMed

ABSTRACT

Background:: Caseous calcification of the mitral annulus (CCMA) is believed to have a benign prognosis. Several authors have recommended conservative management in asymptomatic patients. However, the prevalence of cerebrovascular events (CVE) in patients with CCMA has never been evaluated before. The aims of this study are to investigate whether patients with CCMA are at increased risk of cerebral embolization, and to determine whether elective surgical resection of CCMA should be considered to prevent a cardioembolic stroke.

Methods:: A comprehensive literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, and Google Scholar using the following search queries: caseous calcification of the mitral annulus, intracardiac pseudotumor, mitral annular calcification, and cardioembolic stroke.

Results:: From our initial search that yielded 1,502 articles, we identified a total of 130 patients with CCMA reported in 86 publications. Literature review revealed that the prevalence of CVE associated with CCMA is 19.2% (25 of 130) which is significantly higher than the prevalence of CVE reported with mitral annular calcification (MAC), 11.8% (214 of 1818) (range 4.8% to 24.1%) (P = 0.01796) (odds ratio = 1.78; 0.95 confidence interval = 1.1278 – 2.8239). Only four of 25 (16.0%) patients with CCMA who suffered a CVE had history of atrial fibrillation (AF).

Conclusion:: Based on our review, it would be reasonable to consider elective surgical resection of CCMA in asymptomatic patients who are good surgical candidates, because patients with CCMA may be at increased risk of embolic strokes, which are unrelated to AF.

No MeSH data available.


Related in: MedlinePlus

Microscopic appearance of left middle cerebral artery. The lumen is occluded by amorphous caseous debris material (arrow). Masson trichrome stain. (Reprinted from Pathology International, Volume 62, Issue 7, 2012, 496-499). Taka-aki Matsuyama, Hatsue Ishibashi-Ueda, Yoshihiko Ikeda, Kazuyuki Nagatsuka, Kotaro Miyashita, et al. Critical multi-organ emboli originating from collapsed, vulnerable caseous mitral annular calcification [25]. (Reprinted with permission from John Wiley and sons).
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Figure 3: Microscopic appearance of left middle cerebral artery. The lumen is occluded by amorphous caseous debris material (arrow). Masson trichrome stain. (Reprinted from Pathology International, Volume 62, Issue 7, 2012, 496-499). Taka-aki Matsuyama, Hatsue Ishibashi-Ueda, Yoshihiko Ikeda, Kazuyuki Nagatsuka, Kotaro Miyashita, et al. Critical multi-organ emboli originating from collapsed, vulnerable caseous mitral annular calcification [25]. (Reprinted with permission from John Wiley and sons).

Mentions: Higashi and associates [18] suggested that there was a causal relationship between the CCMA lesion and the stroke, because there was no evidence of extracranial atherosclerosis, and because they were able to demonstrate in one patient that the central cavity within the CCMA communicated with the left atrium (Fig. 2). The authors believed that caseous material leaked from the CCMA lesion into the systemic circulation and embolized to the brain. In another case report, Chevalier and colleagues [20] were able to confirm during surgery a direct communication between the CCMA and the left ventricle in a patient who presented after two strokes, and suggested that spontaneous fistulization is a possible mechanism of embolization of caseous material. Another two articles addressing the issue of possible coexisting extracranial carotid disease suggested that embolization originated from the CCMA lesion, and not from the carotid arteries. Matsuyama and coworkers [25] reported a case where caseous necrotic debris from the CCMA lesion had embolized to the brain and heart in a postmortem exam, in a patient without coexisting extracranial carotid disease (Fig. 3). Sequeira and associates [32] found bilateral branch retinal artery occlusion secondary to calcium and cholesterol emboli in the retinal vessels of a young patient on hemodialysis complaining of visual disturbances, in which the carotid ultrasound did not reveal any plaques within the internal carotid arteries.


Risk of Cerebral Embolization with Caseous Calcification of the Mitral Annulus: Review Article
Microscopic appearance of left middle cerebral artery. The lumen is occluded by amorphous caseous debris material (arrow). Masson trichrome stain. (Reprinted from Pathology International, Volume 62, Issue 7, 2012, 496-499). Taka-aki Matsuyama, Hatsue Ishibashi-Ueda, Yoshihiko Ikeda, Kazuyuki Nagatsuka, Kotaro Miyashita, et al. Critical multi-organ emboli originating from collapsed, vulnerable caseous mitral annular calcification [25]. (Reprinted with permission from John Wiley and sons).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5120388&req=5

Figure 3: Microscopic appearance of left middle cerebral artery. The lumen is occluded by amorphous caseous debris material (arrow). Masson trichrome stain. (Reprinted from Pathology International, Volume 62, Issue 7, 2012, 496-499). Taka-aki Matsuyama, Hatsue Ishibashi-Ueda, Yoshihiko Ikeda, Kazuyuki Nagatsuka, Kotaro Miyashita, et al. Critical multi-organ emboli originating from collapsed, vulnerable caseous mitral annular calcification [25]. (Reprinted with permission from John Wiley and sons).
Mentions: Higashi and associates [18] suggested that there was a causal relationship between the CCMA lesion and the stroke, because there was no evidence of extracranial atherosclerosis, and because they were able to demonstrate in one patient that the central cavity within the CCMA communicated with the left atrium (Fig. 2). The authors believed that caseous material leaked from the CCMA lesion into the systemic circulation and embolized to the brain. In another case report, Chevalier and colleagues [20] were able to confirm during surgery a direct communication between the CCMA and the left ventricle in a patient who presented after two strokes, and suggested that spontaneous fistulization is a possible mechanism of embolization of caseous material. Another two articles addressing the issue of possible coexisting extracranial carotid disease suggested that embolization originated from the CCMA lesion, and not from the carotid arteries. Matsuyama and coworkers [25] reported a case where caseous necrotic debris from the CCMA lesion had embolized to the brain and heart in a postmortem exam, in a patient without coexisting extracranial carotid disease (Fig. 3). Sequeira and associates [32] found bilateral branch retinal artery occlusion secondary to calcium and cholesterol emboli in the retinal vessels of a young patient on hemodialysis complaining of visual disturbances, in which the carotid ultrasound did not reveal any plaques within the internal carotid arteries.

View Article: PubMed Central - PubMed

ABSTRACT

Background:: Caseous calcification of the mitral annulus (CCMA) is believed to have a benign prognosis. Several authors have recommended conservative management in asymptomatic patients. However, the prevalence of cerebrovascular events (CVE) in patients with CCMA has never been evaluated before. The aims of this study are to investigate whether patients with CCMA are at increased risk of cerebral embolization, and to determine whether elective surgical resection of CCMA should be considered to prevent a cardioembolic stroke.

Methods:: A comprehensive literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, and Google Scholar using the following search queries: caseous calcification of the mitral annulus, intracardiac pseudotumor, mitral annular calcification, and cardioembolic stroke.

Results:: From our initial search that yielded 1,502 articles, we identified a total of 130 patients with CCMA reported in 86 publications. Literature review revealed that the prevalence of CVE associated with CCMA is 19.2% (25 of 130) which is significantly higher than the prevalence of CVE reported with mitral annular calcification (MAC), 11.8% (214 of 1818) (range 4.8% to 24.1%) (P = 0.01796) (odds ratio = 1.78; 0.95 confidence interval = 1.1278 – 2.8239). Only four of 25 (16.0%) patients with CCMA who suffered a CVE had history of atrial fibrillation (AF).

Conclusion:: Based on our review, it would be reasonable to consider elective surgical resection of CCMA in asymptomatic patients who are good surgical candidates, because patients with CCMA may be at increased risk of embolic strokes, which are unrelated to AF.

No MeSH data available.


Related in: MedlinePlus